From the Guidelines
Augmentin (amoxicillin-clavulanate) is not recommended for treating Enterobacter cloacae wound infections as this organism typically has intrinsic resistance to this antibiotic, as suggested by the guidelines for management of intra-abdominal infections 1. Ciprofloxacin alone may be appropriate depending on susceptibility testing results. For empiric treatment of Enterobacter cloacae wound infections, I recommend using either ciprofloxacin 500-750 mg orally twice daily or levofloxacin 750 mg once daily for 7-14 days, depending on infection severity. Alternatively, consider a carbapenem (ertapenem, meropenem) or a 3rd/4th generation cephalosporin like cefepime. Enterobacter species produce inducible AmpC beta-lactamases that render them resistant to many beta-lactam antibiotics including amoxicillin-clavulanate. Treatment should ultimately be guided by antimicrobial susceptibility testing results from the wound culture, as emphasized by the guidelines for diagnosis and management of complicated intra-abdominal infection in adults and children 1. Regular wound care with appropriate cleaning and dressing changes is also essential for proper healing alongside antibiotic therapy. Some key points to consider in the management of intra-abdominal infections include:
- The choice of empiric antibiotic regimens should be based on the clinical condition of the patients, the individual risk for infection by resistant pathogens, and the local resistance epidemiology 1.
- Coverage for obligate anaerobic bacilli should be provided for distal small bowel, appendiceal, and colon-derived infection and for more proximal gastrointestinal perforations in the presence of obstruction or paralytic ileus 1.
- For adult patients with mild-to-moderate community-acquired infection, the use of ticarcillin-clavulanate, cefoxitin, ertapenem, moxifloxacin, or tigecycline as single-agent therapy or combinations of metronidazole with cefazolin, cefuroxime, ceftriaxone, cefotaxime, levofloxacin, or ciprofloxacin are preferable to regimens with substantial anti-Pseudomonal activity 1.
From the FDA Drug Label
Skin and Skin Structure Infections caused by Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Proteus mirabilis, Proteus vulgaris, Providencia stuartii, Morganella morganii, Citrobacter freundii, Pseudomonas aeruginosa, methicillin-susceptible Staphylococcus aureus, methicillin-susceptible Staphylococcus epidermidis, or Streptococcus pyogenes The patient can be discharged on ciprofloxacin as it is effective against Enterobacter cloacae in skin and skin structure infections 2. However, it is recommended to perform culture and susceptibility tests before treatment to confirm the susceptibility of the organism to ciprofloxacin.
- Augmentin is not mentioned in the provided drug label, so its effectiveness against Enterobacter cloacae cannot be determined from this information.
- It is essential to note that ciprofloxacin should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria.
From the Research
Treatment of Enterobacter cloacae Infections
The treatment of Enterobacter cloacae infections, particularly those causing wound infections, is a complex issue due to the increasing resistance of this bacterium to various antibiotics 3, 4.
Antibiotic Resistance
Enterobacter cloacae is part of the ESKAPE group, which is characterized by its ability to develop resistance to multiple antibiotics 3. The emergence of multidrug-resistant E. cloacae is a significant problem in healthcare settings, making treatment challenging 3, 4.
Treatment Options
For urinary tract infections (UTIs) caused by E. cloacae, treatment options include nitrofurantoin, fosfomycin, pivmecillinam, fluoroquinolones, and carbapenems 5. However, the use of ciprofloxacin and other fluoroquinolones may be limited due to high rates of resistance 5.
Combination Therapy
Combination therapy, using multiple antibiotics together, may be an effective approach to treat E. cloacae infections, particularly those that are resistant to multiple antibiotics 6. This approach can provide therapeutic synergy, rejuvenate the effectiveness of old antibiotics, and reduce the development of resistance 6.
Specific Treatment for Wound Infections
For a wound infection caused by E. cloacae, the treatment should be guided by antimicrobial susceptibility testing to ensure the chosen antibiotics are effective against the specific strain 3, 4. Augmentin (amoxicillin-clavulanate) and ciprofloxacin may not be the best choices due to potential resistance issues 3, 5. Instead, considering the use of carbapenems or other antibiotics that have been shown to be effective against E. cloacae, such as those mentioned in the treatment options for UTIs, may be more appropriate 5.
Considerations
It is crucial to use antibiotics wisely to avoid the development of further resistance 5, 6. The choice of antibiotic should be based on local susceptibility patterns and the specific characteristics of the infecting strain 3, 4.